Ulnar Thumb Pulp Reconstruction Using the Anterograde Homodigital Neurovascular Island Flap

Outcomes Associated with Moberg and Modified Moberg Flaps in Thumb Reconstruction: A Systematic Review

Background: Appropriate thumb function is critical as it is makes up approximately 40% of the hand's function leading to the greatest influence in activities of daily living (ADLs). Local flaps are the primary option for thumb reconstruction, of which the Moberg flap has been reported to have the added advantage of its advancement capacity relative to other flaps. This systematic review aims to describe the outcomes of the Moberg advancement flap and its associated modifications for coverage of palmar thumb defects. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for the conduct of this systematic review. Medline, Embase, CINAHL and Cochrane Library were systematically searched to retrieve relevant citations. Title and abstract as well as full-text assessment were performed in duplicate. Full texts were extracted by one reviewer and data extracted was confirmed by a second. Complication rates and overall means were calculated for the appropriate outcomes. Results: A total of 1,794 citations were retrieved; 15 papers were retained, including 169 patients. The overall mean follow-up was 28.6 months (n = 5 studies). In 136 patients, there was 100% flap viability (n = 12 studies). With regard to thumb aesthetics, 92% (59/64 patients) had favourable outcomes (n = 6 studies). No evidence of postoperative flexion contractures (n = 0/56 patients, 5 studies) was found. Cold intolerance occurred at a rate of 29.8% (n = 17/57, 4 studies) and the infection rate was 10.3% (6/58 patients, 3 studies). Conclusions: Moberg/modified Moberg flaps are a safe option for thumb reconstruction given their associated postoperative outcome and complication profile. Level of Evidence: Level III (Therapeutic).

A modified Bilhaut-Cloquet procedure for thumb duplication: Reconstruction of functionality and appearance

BACKGROUND

The Bilhaut-Cloquet technique is the preferred surgical method for thumb polydactyly with symmetrical caliber and osseous components. However, the traditional Bilhaut-Cloquet technique has many esthetic and functional complications. In this study, we aimed to investigate an effective modified Bilhaut-Cloquet procedure for Wassel type IV thumb duplication.

METHODS

The dorsal scar of the thumb was hidden on the ulnar side of the thumb through the flap design. The nail bed was sutured flat by combining the phalangeal bone and nail bed on different planes. The sensory function of the thumb was restored by keeping the ulnar skin of the thumb intact.

RESULTS

Our modified Bilhaut-Cloquet procedure did not reduce the mobility of the joints. All patients had relatively rounded fingernails, and no seagull deformity was present. The ulnar side of the palm skin of the thumb remained intact with no scars, maximizing the preservation of the sensory function of the thumb. All the operated children and their parents were satisfied with the esthetic result.

CONCLUSIONS

We hid the surgical scar by improving the surgical method and reducing the thumb seagull nail deformity, and the influencing of the finger sensation caused by the scar on the finger abdomen. The procedure improved not only the appearance of the reconstructed thumbs but also the sensory function of the thumbs.

Soft and tissue repair of the hand and digital reconstruction

This article summarizes the current views and proposed approaches to treating soft tissue defects of the hand. The article also outlines some key considerations of digital reconstruction. There are many options in treating soft tissue defects. For defects of the hand, local flaps are primarily considered if the defects are small or moderate in size. A vascularized free flap is only considered for a defect of large size (3 cm long or larger). Thumb reconstruction is of primary importance, while reconstruction of two fingers is necessary when all fingers are lost. Reconstructions of a missing distal part of a finger or reconstruction of an entire finger if only one finger is lost are cosmetic restorations; functionally these defects do not need reconstruction. Sensation is of great importance in repair or reconstruction of the tip of the thumb or finger. Therefore, sensory evaluation is a key factor in assessing and selecting the best options of surgery.

Expanding indication of free hypothenar flap transfer: Sequential pedicled ulnar palm flap transfer to a relatively large hypothenar flap donor site

BACKGROUND

Free hypothenar flap (HTF) transfer allows sensible soft tissue reconstruction of the fingertip. However, HTF is basically indicated for a relatively small soft tissue defect, as width of an HTF is limited up to approximately 20 mm to allow primary donor site closure. Combined with sequential local flap to an HTF donor site, a larger HTF can be used without the contracture risk. The aim of this study was to evaluate feasibility of free HTF transfer and sequential ulnar palm flap (UPF) transfer (HTF-UPF) for relatively large fingertip reconstructions.

METHODS

Medical charts of patients who underwent HTF-UPF for fingertip reconstruction were reviewed. An HTF was designed transversely proximal to the proximal palmar crease, and a slightly smaller hemi-spindle-shaped UPF was designed longitudinally on the mid-lateral aspect of the ulnar palm; the UPF was used to close the HTF donor site. Patient and flap characteristics, intra-operative findings, and postoperative results were evaluated.

RESULTS

Twelve patients with average age of 42.7 years were included. HTF-UPF procedure was performed on 12 fingers. HTF's length/width ranged from 45/20 to 70/40 mm (average, 52.5/32.1 mm). UPF's length/width ranged from 40/20 to 55/30 mm (average, 46.7/24.2 mm). Time for sequential UPF transfer ranged from 3 to 9 min (average, 5.1 min). All HTFs and UPFs survived without flap necrosis or scar contracture. Postoperative sensation was comparable with the contralateral fingertip.

CONCLUSIONS

HTF-UPF procedure allows relatively large fingertip reconstruction with a minimum risk of HTF donor site contracture.

Anatomic Considerations and Reconstruction of the Thumb Flexor Pulley System

Disruption to the flexor pulley system of the thumb is an infrequent but devastating injury that can lead to significant compromise in both strength and function. Acute rupture leads to pain, weakness, reduced range of motion (ROM), and potential bowstringing of the flexor tendons. Conservative treatment with a pulley ring should be considered in all patients. However, failure of conservative treatment and bowstringing of the thumb are indications for operative intervention. Reconstruction of the oblique pulley system can be performed either in situ or using a free palmaris longus graft. Care should be taken to identify the neurovascular bundles to avoid compression during the reconstruction. Conscious sedation protocols augmented by ultrasound-guided sheath blocks allow the patient to actively and strongly contract the flexor pollicis longus tendon intraoperatively to appropriately tension the construct for optimal results. Rehabilitation should be performed in a stepwise manner beginning with early passive ROM, active ROM, and finally strengthening at around 8 weeks postoperative.